New Approaches to the Opioid Crisis and Pain Management in California

By Aaron Hemmings, Shareholder, Stander Reubens Thomas Kinsey (SRTK)

The opioid crisis is one of America’s largest. According to a National Institute of Health study, updated in February 2018, 115 Americans die every day from an opioid medication overdose. California is not immune to this problem, and it greatly affects the California workers compensation system. According to a California Workers Compensation Institute study, the use of Schedule II and Schedule III opioids has been increasing over the past several years. This upward trend has resulted in a search within California’s workers compensation system to provide new pain management treatments.

The California Department of Industrial Relations Division of Workers Compensation (DWC), in order to minimize the impact of the opioid crisis within the system, is pushing for ways to implement evidence-based medicine pain management treatment protocols. AB 1124 directed the DWC to adopt an evidence-based medicine approach for a drug formulary that follows the ACOEM Guidelines. The Medical Treatment Utilization Schedule (MTUS) for Drug Formulary adopted the ACOEM Guidelines on December 1, 2017. The regulations surrounding the formulary were approved by the Office of Administrative Law on December 7, 2017. The primary role of the MTUS is to give a medical evidence search sequence for treatment recommendations and thus give guidance to treaters in the California workers compensation system as to which medications – including opioids – are the most effective and appropriate. The MTUS is designed to be the primary source of guidance for treaters in the California workers compensation system. The approach looks at the diagnosis and matches the proposed medication to it. The overall approach for physicians mirrors what the Centers For Disease Control (CDC) calls the “start low and go slow” concept.  The MTUS Drug Formulary applies to drugs dispensed on or after January 1, 2018 and applies to all dates of injury. However, a “phase in” provision was created for patient safety that allows treating physicians until April 1, 2018 to provide for a progress report and a “Request For Authorization” to address an ongoing treatment plan, which includes opioid medications.  

The goal of the formulary is to limit the use of opioid medications for severe acute pain without any sort of delay due to Utilization Review. According to the CDC, three or less days are often sufficient, and more than seven days of opioid medications will rarely be needed. A “special fill” policy was included in the legislation to implement the CDC’s recommendations. Ultimately, extended use of these medications must be certified by Utilization Review. Statistics have shown that return to work times decrease as pain medication usage decreases. Furthermore, the level of permanent disability and the costs of future medical care are lower when there are less opioids being used to treat the injured worker. The DIR considered this formulary to be a “win-win” for both applicants and employers.

Apart from the ACOEM Guidelines, other evidence-based medicine approaches have been added to the MTUS. These guidelines address issues related to asthma, lung disease and stress related conditions. It is hoped the approach to traditional orthopedic injuries can be implemented for these conditions in the future.

Other approaches to pain management are also being considered in the California workers compensation system. New studies suggest the old approaches for treating pain are incomplete and a “biopsychosocial” approach contemplating issues of cultural background, belief systems, workplace environment, support systems and even the perception and expression of “pain” itself are being reevaluated. With recognition of these factors, it is hoped that the treating physicians will be able to treat both acute and chronic pain by identifying “at risk” patients and implementing the best possible treatment approaches. In the past, the DIR has expressed interest in incorporating these approaches into their evidence-based medicine approach that will hopefully be another “win-win” for all stakeholders in the system.